Power dynamics in patient-provider relationship offer ‘fertile arena for gaslighting’

The word “gaslighting” has taken on a life of its own in recent years, being used in the context of interpersonal relationships, political discourse and online chatter.

But really, it is just another name for something that many patients with gastrointestinal disease have been experiencing for decades.

“Gaslighting refers to a form of cognitive manipulation within an interpersonal relationship in which a more powerful person sows seeds of doubt in a less powerful individual, making them question their own perception, judgment, feelings and/or sanity,” Priya Fielding-Singh, PhD, assistant professor in the department of family and consumer studies at the University of Utah, told Healio Gastroenterology. “This can occur in different types of relationships and in different settings, including medical settings.”

The term draws its name from the 1944 film “Gaslight” and has been known and used among psychiatry and psychology circles for decades. However, the term has recently exploded in popularity, often used as shorthand for various forms of deception and manipulation, including fake news, conspiracy theories, Twitter trolls and deepfakes. Merriam-Webster Dictionary even declared “gaslighting” its 2022 Word of the Year.

In a medical context, a health care provider’s attitude or behavior may make patients feel as though their symptoms or perception of their body functioning are inaccurate or not based on reality, Tiffany H. Taft, PsyD, research associate professor of medicine, psychiatry and behavioral sciences at Northwestern University Feinberg School of Medicine, explained.

“Patients have been using the term for a while, especially as the word gaslighting has become more common in the vernacular of the U.S.,” she said. “As you can imagine, labeling the behavior of medical providers as gaslighting is very emotionally charged, considering it is a term typically applied to abusive partners or other people in positions of authority who aim to control another person.

“We have to recognize that gaslighting is a severe word, it has a lot of stigma [and] a lot of negative connotation because it is such a broad thing.”

Taft noted there is little research on gaslighting in the medical space and specifically in gastroenterology, in part because it is such a difficult topic to study. Current literature focuses on “traditional sources of abuse, like domestic violence or other interpersonal relationships,” she said, and there is no validated questionnaire to evaluate gaslighting experiences in a medical context, nor is there one to assess gaslighting behavior in a clinician.

According to Meredith R. Craven, PhD, MPH, a clinical health psychologist and director of GI health psychology in the division of gastroenterology and hepatology at Stanford University, medical gaslighting may lead to longer time to diagnosis and impact patient-provider relationships, drive mistrust in the health care system and affect medical adherence and patient outcomes.

Health care providers who were taught to use the biomedical model may find it difficult to diagnose patients with disorders of the gut-brain interaction or irritable bowel syndrome, whose GI symptoms fall outside the typical parameters, since test results might indicate they are “fine,” she said. Therefore, these providers may not properly diagnose patients because they believe patient symptoms may just be due to anxiety or stress. Craven noted this can be an key issue in disorders of gut-brain interaction and irritable bowel syndrome as they are highly prevalent in patients and there remains poor understanding on the pathophysiology, limited treatments options and persistent refractory symptoms.

Craven said providers instead need to use a biopsychosocial model, incorporating biological, psychological and social factors into health, well-being and disease to “recognize the influence and interplay that these factors can have on health and symptoms.”

She added: “This is why it is so important for providers to give a clear biopsychosocial explanation of IBS to patients, emphasizing that it is legitimate and compassionately sharing that managing stress and taking care of one’s mental health are an important part of IBS treatment.”

Additionally, Taft noted when a patient does not feel well, their mood can be impacted.

“They will be concerned about what is going on in their body, and if met with dismissal or gaslighting behaviors by a medical provider, this can amplify low mood and worry, instill doubt in their own lived experience and cause frustration and anger,” she said.

These feelings disrupt communication between the doctor and patient and exacerbate gaslighting.

Further complicating the matter is that certain groups — including women, the LGBTQ community and people of color — have historically had reason to mistrust the health care system. Combine an uncertain GI diagnosis with this inherent mistrust, born from systemic prejudice, and the result is that many women and patients from underrepresented communities feel as though they are being gaslit.

Although solutions to such complex structural problems never come easy, emerging experts like Jen Sebring, BA(H), MSc, a research assistant and graduate student in the department of community health sciences at Max Rady College of Medicine in Winnipeg, Canada, provided a starting point.

“Make a plan,” they said. “Give referrals when and where necessary. Be transparent with your patients. Walk them through your thought process when appropriate.”

From there, it may be possible to begin building the all-important trust that so many gastroenterologists describe as the cornerstone of their practice. However, first it may be necessary to gain a deeper understanding of the general concept of gaslighting itself.

‘They Have Not Been Believed’

It is essential to note that although many people who gaslight others do so intentionally, gaslighting does not have to be an intentional act, according to Fielding-Singh.

“It’s important to keep in mind that, in some instances, gaslighting can occur without the conscious intent of the person doing it,” she said.

Taft noted gaslighting may occur due to physician burnout, because physicians are stressed and may say things to patients that may be hurtful even without intending to or even being aware of it.

To break the cycle of medical gaslighting, Taft suggested “the [health care] system needs a massive overhaul, so clinicians feel supported and are not bogged down with paperwork and fighting insurance denials, and those who do engage in gaslighting behavior are identified, receive interventions, and if they continue, receive appropriate consequence.”

Part of the issue is that institutional constraints within the context of medicine place pressure on physicians, according to Fielding-Singh. Doctors are often up against a lack of time and resources, which can make those challenging diagnoses even more difficult and less grounded in productive communication.

However, Fielding-Singh added that these constraints are often accompanied by “embedded hierarchies and gender inequalities that provide the terrain upon which gaslighting can flourish.”

The result, she said, is that gaslighting becomes not just an interpersonal phenomenon, but a form of what she calls “structural violence.”

That violence can play out in a clinical setting, Fielding-Singh added.

“When we talk about medical gaslighting in particular, compared with general disrespect or maltreatment of patients by providers, we should be sure that we are referring to a kind of maltreatment that constructs patients as noncredible or crazy,” she said. “That’s what makes it gaslighting.”

According to Taft, medical gaslighting can trigger a patient with prior medical or non-medical trauma and lead to them feeling dismissed and unheard, which could be devastating for patients.

“You are being made to feel that your experience is not real, and for somebody with a trauma history that can be very distressing. It can elicit shame,” she said.

Through her work as director of patient-centered research operations and ethical oversight at the Global Healthy Living Foundation, Shilpa Venkatachalam, PhD, MPH, has extensively discussed such topics with patients.

“We have a lot of anecdotal conversations with patients on various topics related to their experience with diagnosis and decision-making around management and treatment of their disease; several have shared instances about their experiences when either their symptoms were inappropriately addressed, or they have not been believed,” she said.

Sometimes, the “explanation” given to patients was that the symptoms were simply unexplainable, according to Venkatachalam.

“In other cases, we have heard that they were told that their condition or symptoms were primarily psychological, and that there was no medical diagnosis to be given,” she said.

Depression or anxiety sometimes became scapegoats for what they were experiencing, which Venkatachalam suggested was just one type of gaslighting they reported.

Additionally, Taft noted “medically unexplained symptoms” are most prone to gaslighting, especially when a patient’s reported symptoms are not supported by diagnostic tests or physiological data.

Although there have been many advancements in IBS and other disorders of gut-brain interaction, she said these conditions are often similarly classified as “medically unexplained” because results from a colonoscopy were normal or laboratory markers were within the normal range.

“With that being said, gaslighting can also happen to patients with conditions like inflammatory bowel disease or eosinophilic esophagitis if the disease is in remission per medical workup, but symptoms persist,” Taft said. “In this case, the person ‘should be feeling better’ so gaslighting can ensue.”

Further, Craven said physicians at times are frustrated by patients with refractory symptoms, which can cause patients to feel invalidated or dismissed or rejected. Often times, these refractory symptoms can be attributed to a patient’s mental health.

Understanding a patient and validating their experience may reduce the incidence of gaslighting in any given clinic.

Health Care ‘Is Not Just About Access’

Changing the paradigm means changing the way health care is being taught at the source. According to Craven, there should be less focus on the biomedical model and more on the biopsychosocial model and biopsychosocial cultural model, which focus on the cultural or psychosocial factors that may be influencing and driving the symptom experience.

Providers should understand how these factors affect patients and how important a patient’s context and history is.

As of late, reimbursements have been a primary focus in health care, Craven said, and there needs to be a shift toward the patient experience and how it can be improved, especially when dealing with disparities. Additionally, she noted there has been a large focus on increasing patient access to care in order to decrease heath care disparities.

“If a patient does not feel like they can connect to the provider or feels like the provider is biased or is gaslighting them, they are not going to want to come back,” Craven said. “It is not just about access [to care]; it is making the patient experience better.”

In a paper published in the Journal of Patient Experience, Vargas and Mahalingam use the term “incivility” as a catch-all for unsatisfactory doctor-patient interactions. They questioned 173 patients to determine experiences of incivility in a hospital setting.

Results yielded six major themes of incivility: Insensitivity, identity stigma, gaslighting, infantilization, poor communication and being ignored.

“The findings highlight that instances of incivility are present in almost all aspects of the patient experience and take on unique forms, given the patient’s role in the hospital,” they wrote.

Clearly, it is essential for gastroenterologists to maintain civility with all patients. However, certain groups, historically, have faced even greater challenges in health care settings and may require specific and ongoing attention to prevent gaslighting.

Women are ‘Not Taken Seriously’

In a paper published in Sociology of Health and Illness, Sebring wrote that as the term “medical gaslighting” has arisen, women in particular have experienced “invalidation, dismissal and inadequate care.”

According to Sebring, the explanation for this phenomenon is not simply a personal misunderstanding between doctor and patient, “but the result of deeply embedded and largely unchallenged ideologies underpinning health care services.”

Craven noted that, historically, women have been more likely to be diagnosed with certain GI conditions linked to anxiety and depression, such as IBS and gastroparesis.

“There has been an enduring perspective that if a condition is more likely to occur in women, then it must reflect some kind of psychopathology — like anxiety, for example,” Craven said. “This perspective is shifting but is still somewhat held in the field today.” Fielding-Singh added that gaslighting also often relies on gendered stereotypes of women as “irrational, hysterical or dramatic.”

“These gendered stereotypes that shape medical providers’ views of women patients as less rational, more emotional and more likely to complain than men come from gendered ideology within medical science itself,” she said. “Theories of male superiority are embedded in biological claims that men are whole and strong, while women are weak and incomplete.”

Fielding-Singh stressed that gaslighting almost always occurs within relationships in which the power is unevenly distributed.

“For gaslighting to be effective, it generally has to be facilitated by an existing unequal power dynamic,” she said. “Usually, the gaslighter holds more power than the victim, often to the point where the victim depends on the gaslighter or cannot exit the relationship.”

As such, a gaslighting situation is “rarely gender-neutral,” according to Fielding-Singh.

“Rather, it is a largely gendered phenomenon, both within and beyond medicine, given the fact that women rarely possess the cultural, economic and political capital required to gaslight men,” she said. “In medicine, the underlying dynamics of power, vulnerability and dependence in the relationship between provider and patient make the clinical encounter an especially fertile arena for gaslighting to occur.”

Further explanation on this can be found in the Sebring paper. Medical gaslighting is “commonplace” not just among women, but also “transgender, intersex, queer and racialized individuals seeking health care,” they wrote.

In short, Sebring suggested that medical gaslighting is the result of health care inequities that are rooted in broader structural and systemic inequities. With this in mind, it is unsurprising that many patients of color also report gaslighting with greater frequency than their white counterparts.

Racism and Distrust

Further findings from Sebring’s MSc thesis showed that Indigenous and Latino participants reported being subjected to racial stereotypes while seeking care.

“For example, one participant was used to having her pain dismissed because of her race, which made her hesitant to seek care at all,” Sebring said.

This anecdote highlights the intimacy of health care interactions, and how frustrated and disappointed patients can feel when that intimacy is violated.

Venkatachalam suggested that these failures in interpersonal interaction begin much earlier than any individual doctor-patient relationship.

“Medical gaslighting is not just about an interpersonal exchange, but rather reflects a sociological issue,” Craven noted, commenting on Sebring’s paper. “Our medical system is a reflection of society, and structural racism and structural sexism are a part of that society.”

She added that, unless confronted during the course of medical training, these inherent racial and gender biases will be passed onto providers in medical school and perpetuate current health disparities.

“More medical schools are shifting away from the biomedical model and to a biopsychosocial [model], but this model is still very prevalent,” she said. “There is still a lot of bias in medicine that unfortunately impacts these minority groups.”

It may therefore take significantly longer to arrive at a diagnosis for people of color as symptoms are missed because of system-level barriers, discrimination and medical racism, and can contribute medical gaslighting, according to Venkatachalam.

“But of course, it is not always the fault of the physician,” she said. “It is a systemic issue that we need to address. Most physicians want to help their patients and sometimes certain diseases may have symptoms that slowly present over a period of time, or that could indicate other conditions too that need to be ruled out first, along with insurance and access issues that can lead to delays in diagnosis.”

However, the issue is still bigger than that.

“We have to consider that, at the population level, many Black patients have a mistrust of the health care system for a number of reasons, including a deeply embedded historical legacy of exploitation, dismissal and violence in health care,” Venkatachalam said.

The history of how Black Americans have been treated with regard to medicine in the U.S. is long and sordid. The infamous Tuskegee Syphilis Study is but the most well-known example, but others continue to this day — as of 2020, the maternal mortality rate for non-Hispanic Black women was 2.9 times the rate for non-Hispanic white women, according to the CDC. The result is a level of mistrust that can play out across the spectrum of health care.

In a 2019 paper published in Behavioral Medicine, Powell and colleagues found that African American men were significantly more likely than their white counterparts to delay blood pressure and cholesterol screenings as well as routine checkups.

“Increasing preventive health screening among African American men requires addressing medical mistrust and racism in and outside health care institutions,” they wrote.

Every provider should be careful about reasserting these “paradigms of distrust,” according to Venkatachalam.

If there is another fundamental problem in the U.S. that may have implications in medical gaslighting, it is increasing rates of mental health comorbidities.

Pain, Shame and Mental Health

In a paper published in Frontiers in Psychology, Boring and colleagues noted that although pain is subjective, “many people have their pain invalidated or not believed.” They drew associations between pain invalidation and poor mental health, including depression and a lower sense of well-being. In their study, they asked participants to discuss times when pain was invalidated, not only by family and friends, but by medical professionals. They then assessed the association between this invalidation and mental health outcomes like depression or shame.

“Overall, findings indicate that one mechanism by which pain invalidation may facilitate depression is via the experience of shame,” they wrote.

Taft echoed what Boring and colleagues wrote, describing symptoms as a “subjective experience of physical sensations” and that they do not have to “jibe with what an MRI or blood test says.”

“That is what the patient is experiencing, and it is valid,” she said. “I do not know what the harm would be to validate symptoms that do not align necessarily with testing.”

According to Sebring, interrupting this link could be beneficial in minimizing the feeling of being gaslit. However, this is no easy task, they added.

“You have to consider the broader context of mental health, which comes with its own stigmas,” they said. “So, when a physician says something is psychological, it is read as dismissal. It is a tricky area to navigate.”

The message here is that if the patient is still feeling unwell physically at this point, then perhaps measures to address mental health issues will bear fruit.

This approach is just one of many possible solutions to manage the problem of gaslighting in medicine.

Practical Solutions

Physicians must use active-listening skills, take time with patients and understand their symptoms and how they impact their lives, Craven suggested. They should remind patients they are being heard, validate their feelings and empathize with them.

“The other piece of this is goal setting, of helping patients by collaborating with them on realistic goals,” she said. “That is going to help a patient feel heard and that the physician is taking a patient-centered approach.”

Craven suggests physicians turn to the Rome Foundation for guidance and resources on how to improve communication with their patients, particularly those with disorders of gut-brain interaction.

“There needs to be more education for providers to be more sensitive to the language and the cultural context any given patient may come from and use to describe their symptoms,” Venkatachalam said.

Regarding the language providers use, Venkatachalam suggested moving away from words like “unexplainable,” “tricky” or “unusual” to describe something a patient is feeling.

“These words are part of gaslighting culture,” she said. “If you are listening empathetically, you will understand that regardless of what the exam or the lab test results say, if they are feeling it, it is part of their experience, and it needs to be recognized.”

Data can help minimize gaslighting, as can technology, according to Venkatachalam.

“There are a number of ways for patients to generate their own information, from symptom journals ... to wearable technologies that track all kinds of information,” she said.

The thinking is that if a patient can characterize their pain, or if a device can register movement or sleep on a daily basis, the data will tell the story in a way that the patient may not. The data-driven evidence of journal entries and Fitbit numbers can fill the areas of misremembering and miscommunication where gaslighting begins.

The key is time, according to Venkatachalam.

“If we see what a patient is experiencing over time, we can begin to identify patterns,” she said. “Those patterns will help us more clearly identify the issue.”

Every health care provider needs to understand the gravity of a patient going to a clinic and seeking care, according to Sebring.

“For people who have experienced invalidation when seeking care before, they are often quite hesitant to seek care at all,” Sebring said. “People often feel quite vulnerable in doing so.”

Respecting the leap patients have taken and the vulnerability they are feeling from the first contact is critical to minimizing the likelihood of gaslighting, they added.

“What they are experiencing is real and impactful for them,” they said. “It is of the utmost importance to recognize that and try to work with them to come up with a solution, or a plan for moving forward.”

• References:
• Boring BL, et al. Front Psychol. 2021;doi:10.3389/fpsyg.2021.743584.
• Powell W, et al. Behav Med. 2019;doi:10.1080/08964289.2019.1585327.
• Sebring JCH. Sociol Health Illn. 2021;doi: 10.1111/1467-9566.13367.
• Vargas EA, Mahalingam R. J Patient Exp. 2020;doi:10.1177/2374373519878037.

• For more information:
• Meredith R. Craven, PhD, MPH, can be reached at mrcraven@stanford.edu.
• Priya Fielding-Singh, PhD, can be reached at priya.fielding-singh@fcs.utah.edu.
• Jen Sebring, BA(H), MSc, can be reached at jennifer.sebring@umanitoba.ca.
• Tiffany H. Taft, PsyD, can be reached at ttaft@opbmed.com.
• Shilpa Venkatachalam, PhD, MPH, can be reached at jdaitch@ghlf.org.